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1.  Data sharing between home care professionals: a feasibility study using the RAI Home Care instrument 
BMC Geriatrics  2014;14:81.
Background
Across Ontario, home care professionals collect standardized information on each client using the Resident Assessment for Home Care (RAI-HC). However, this information is not consistently shared with those professionals who provide services in the client’s home. In this pilot study, we examined the feasibility of sharing data, from the RAI-HC, between care coordinators and service providers.
Methods
All participants were involved in a one-day training session on the RAI-HC. The care coordinators shared specific outputs from the RAI-HC, including the embedded health index scales, with their contracted physiotherapy and occupational therapy service providers. Two focus groups were held, one with care coordinators (n = 4) and one with contracted service providers (n = 6). They were asked for their opinions on the positive aspects of the project and areas for improvement.
Results
The focus groups revealed a number of positive outcomes related to the project including the use of a falls prevention brochure and an increased level of communication between professionals. The participants also cited multiple areas for improvement related to data sharing (e.g., time constraints, data being sent in a timely fashion) and to their standard practices in the community (e.g., busy workloads, difficulties in data sharing, duplication of assessments between professionals).
Conclusions
Home care professionals were able to share select pieces of information generated from the RAI-HC system and this project enhanced the level of communication between the two groups of professionals. However, a single information session was not adequate training for the rehabilitation professionals, who do not use the RAI-HC as part of normal practice. Better education, ongoing support and timely access to the RAI-HC data are some ways to improve the usefulness of this information for busy home care providers.
doi:10.1186/1471-2318-14-81
PMCID: PMC4083131  PMID: 24975375
Home care; Rehabilitation; InterRAI; Standardized assessment; Information sharing
2.  Supporting residents’ expression of sexuality: the initial construction of a sexuality assessment tool for residential aged care facilities 
BMC Geriatrics  2014;14:82.
Background
Sexuality is a key component of quality of life and well-being and a need to express one’s sexuality continues into old age. Staff and families in residential aged care facilities often find expressions of sexuality by residents, particularly those living with dementia, challenging and facilities often struggle to address individuals’ needs in this area. This paper describes the development of an assessment tool which enables residential aged care facilities to identify how supportive their organisation is of all residents’ expression of their sexuality, and thereby improve where required.
Methods
Multi-phase design using qualitative methods and a Delphi technique. Tool items were derived from the literature and verified by qualitative interviews with aged care facility staff, residents and families. The final item pool was confirmed via a reactive Delphi process.
Results
A final item pool of sixty-nine items grouped into seven key areas allows facilities to score their compliance with the areas identified as being supportive of older people’s expression of their sexuality in a residential aged care environment.
Conclusions
The sexuality assessment tool (SexAT) guides practice to support the normalization of sexuality in aged care homes and assists facilities to identify where enhancements to the environment, policies, procedures and practices, information and education/training are required. The tool also enables facilities to monitor initiatives in these areas over time.
doi:10.1186/1471-2318-14-82
PMCID: PMC4085662  PMID: 24980463
Sexuality; Tool development; Older people; Residential aged care; Dementia
3.  Alterations in proton leak, oxidative status and uncoupling protein 3 content in skeletal muscle subsarcolemmal and intermyofibrillar mitochondria in old rats 
BMC Geriatrics  2014;14:79.
Background
We considered of interest to evaluate how aging affects mitochondrial function in skeletal muscle.
Methods
We measured mitochondrial oxidative capacity and proton leak, together with lipid oxidative damage, superoxide dismutase specific activity and uncoupling protein 3 content, in subsarcolemmal and intermyofibrillar mitochondria from adult (six months) and old (two years) rats. Body composition, resting metabolic rate and plasma non esterified fatty acid levels were also assessed.
Results
Old rats displayed significantly higher body energy and lipids, while body proteins were significantly lower, compared to adult rats. In addition, plasma non esterified fatty acid levels were significantly higher, while resting metabolic rates were found to be significantly lower, in old rats compared to adult ones. Significantly lower oxidative capacities in whole tissue homogenates and in intermyofibrillar and subsarcolemmal mitochondria were found in old rats compared to adult ones. Subsarcolemmal and intermyofibrillar mitochondria from old rats exhibited a significantly lower proton leak rate, while oxidative damage was found to be significantly higher only in subsarcolemmal mitochondria. Mitochondrial superoxide dismutase specific activity was not significantly affected in old rats, while significantly higher content of uncoupling protein 3 was found in both mitochondrial populations from old rats compared to adult ones, although the magnitude of the increase was lower in subsarcolemmal than in intermyofibrillar mitochondria.
Conclusions
The decrease in oxidative capacity and proton leak in intermyofibrillar and subsarcolemmal mitochondria could induce a decline in energy expenditure and thus contribute to the reduced resting metabolic rate found in old rats, while oxidative damage is present only in subsarcolemmal mitochondria.
doi:10.1186/1471-2318-14-79
PMCID: PMC4075979  PMID: 24950599
Mitochondria; Aging; Oxidative stress
4.  An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT) 
BMC Geriatrics  2014;14:78.
Background
In line with a rapidly ageing global population, the rise in the frequency of falls will lead to increased healthcare and social care costs. This study will be one of the few randomized controlled trials evaluating a multifaceted falls intervention in a low-middle income, culturally-diverse older Asian community. The primary objective of our paper is to evaluate whether individually tailored multifactorial interventions will successfully reduce the number of falls among older adults.
Methods
Three hundred community-dwelling older Malaysian adults with a history of (i) two or more falls, or (ii) one injurious fall in the past 12 months will be recruited. Baseline assessment will include cardiovascular, frailty, fracture risk, psychological factors, gait and balance, activities of daily living and visual assessments. Fallers will be randomized into 2 groups: to receive tailored multifactorial interventions (intervention group); or given lifestyle advice with continued conventional care (control group). Multifactorial interventions will target 6 specific risk factors. All participants will be re-assessed after 12 months. The primary outcome measure will be fall recurrence, measured with monthly falls diaries. Secondary outcomes include falls risk factors; and psychological measures including fear of falling, and quality of life.
Discussion
Previous studies evaluating multifactorial interventions in falls have reported variable outcomes. Given likely cultural, personal, lifestyle and health service differences in Asian countries, it is vital that individually-tailored multifaceted interventions are evaluated in an Asian population to determine applicability of these interventions in our setting. If successful, these approaches have the potential for widespread application in geriatric healthcare services, will reduce the projected escalation of falls and fall-related injuries, and improve the quality of life of our older community.
Trial registration
ISRCTN11674947
doi:10.1186/1471-2318-14-78
PMCID: PMC4080753  PMID: 24951180
Accidental falls; Aged; Asians; Randomized controlled trial; Fear of falling; Quality of life
5.  Late-life depression and quality of life in a geriatric evaluation and management unit: an exploratory study 
BMC Geriatrics  2014;14:77.
Background
Late-life depression is common among elderly patients. Ignorance of the health problem, either because of under-diagnosis or under-treatment, causes additional medical cost and comorbidity. For a better health and quality of life (QoL), evaluation, prevention and treatment of late-life depression in elderly patients is essential.
Methods
This study examined (1) the differences of clinical characteristics, degree of improvement on QoL and functionality on discharge between non-depressed and depressed elderly inpatients and (2) factors associated with QoL on discharge. Four hundred and seventy-one elderly inpatients admitted to a geriatric evaluation and management unit (GEMU) from 2009 to 2010 were enrolled in this study. Comprehensive geriatric assessment including the activities of daily living (ADL), geriatric depression scale, and mini-mental state examination were conducted. QoL was assessed using the European Quality of Life-5 Dimensions and the European Quality of Life-5 Dimensions Visual Analog Scale on discharge. Information on hospital stay and Charlson comorbidity index were obtained by chart review. Chi-square tests, independent t-tests, Mann–Whitney U tests and multiple linear regressions were used in statistical analysis.
Results
Worse QoL and ADL on discharge were found among the depressed. Depressive symptoms, female gender, duration of hospital stay, and rehabilitation were significant factors affecting QoL on discharge in linear regression models.
Conclusions
The importance of the diagnosis and treatment of depression among elderly inpatients should not be overlooked during hospital stay and after discharge. Greater efforts should be made to improve intervention with depressed elderly inpatients.
doi:10.1186/1471-2318-14-77
PMCID: PMC4085690  PMID: 24941865
Elderly; Late-life depression; Geriatric depression; Quality of life; EQ-5D; Geriatric evaluation and management unit; GEMU; ADL; GDS
6.  Age and gender differences in the prevalence and patterns of multimorbidity in the older population 
BMC Geriatrics  2014;14:75.
Background
The coexistence of several chronic diseases in one same individual, known as multimorbidity, is an important challenge facing health care systems in developed countries. Recent studies have revealed the existence of multimorbidity patterns clustering systematically associated distinct clinical entities. We sought to describe age and gender differences in the prevalence and patterns of multimorbidity in men and women over 65 years.
Methods
Observational retrospective multicentre study based on diagnostic information gathered from electronic medical records of 19 primary care centres in Aragon and Catalonia. Multimorbidity patterns were identified through exploratory factor analysis. We performed a descriptive analysis of previously obtained patterns (i.e. cardiometabolic (CM), mechanical (MEC) and psychogeriatric (PG)) and the diseases included in the patterns stratifying by sex and age group.
Results
67.5% of the aged population suffered two or more chronic diseases. 32.2% of men and 45.3% of women were assigned to at least one specific pattern of multimorbidity, and 4.6% of men and 8% of women presented more than one pattern simultaneously. Among women over 65 years the most frequent pattern was the MEC pattern (33.3%), whereas among men it was the CM pattern (21.2%). While the prevalence of the CM and MEC patterns decreased with age, the PG pattern showed a higher prevalence in the older age groups.
Conclusions
Significant gender differences were observed in the prevalence of multimorbidity patterns, women showing a higher prevalence of the MEC and PG patterns, as well as a higher degree of pattern overlapping, probably due to a higher life expectancy and/or worse health. Future studies on multimorbidity patterns should take into account these differences and, therefore, the study of multimorbidity and its impact should be stratified by age and sex.
doi:10.1186/1471-2318-14-75
PMCID: PMC4070347  PMID: 24934411
Multimorbidity; Comorbidity; Chronic disease; Primary health care; Prevalence; Frail elderly
7.  Health care resource utilisation in primary care prior to and after a diagnosis of Alzheimer’s disease: a retrospective, matched case–control study in the United Kingdom 
BMC Geriatrics  2014;14:76.
Background
This study examined medical resource utilisation patterns in the United Kingdom (UK) prior to and following Alzheimer’s disease (AD) diagnosis.
Methods
A patient cohort aged 65 years and older with newly diagnosed AD between January 2008 and December 2010 was identified through the UK’s Clinical Practice Research Datalink (CPRD). Patients with a continuous record in the CPRD (formerly the General Practice Research Database [GPRD]) for both the 3 years prior to, and the 1 year following, AD diagnosis were eligible for inclusion. A control cohort was identified by matching general older adult (GOA) patients to patients with AD based on year of birth, gender, region, and Charlson Comorbidity Index at a ratio of 2:1. Medical resource utilisation was calculated in 6-month intervals over the 4-year study period. Comparisons between AD and GOA control cohorts were conducted using conditional logistic regression for patient characteristics and a generalised linear model for resource utilisation.
Results
Data for the AD cohort (N = 3,896) and matched GOA control cohort (N = 7,792) were extracted from the CPRD. The groups were 65% female and the AD cohort had a mean age of 79.9 years (standard deviation 6.5 years) at the date of diagnosis. Over the entire study period, the AD cohort had a significantly higher mean primary care consultation rate than the GOA cohort (p < .0001). While the GOA cohort primary care consultation rate gradually increased over the 4-year period (ranging from 5 to 7 consultations per 6-month period), increases were more pronounced in the AD cohort (ranging from 6 to 11 consultations per 6-month period, peaking during the 6-month periods immediately prior to and post diagnosis). The AD cohort also had a higher overall specialty referral rate than the GOA cohort over the 4-year period (37% vs. 25%, respectively; p < .0001); the largest difference was during the 6 months immediately prior to AD diagnosis (17% vs. 5%, respectively; p < .0001).
Conclusions
In the UK, AD diagnosis is associated with significant increases in primary and secondary care resource utilisation, continuing beyond diagnosis. This evidence may be important to health care commissioners to facilitate effective mobilisation of appropriate AD-related health care resources.
doi:10.1186/1471-2318-14-76
PMCID: PMC4073513  PMID: 24934556
Alzheimer’s disease; Dementia; United Kingdom; Primary care
8.  Effects of omega 3 supplementation in elderly patients with acute myocardial infarction: design of a prospective randomized placebo controlled study 
BMC Geriatrics  2014;14:74.
Background
Both epidemiological and randomized clinical studies suggest that supplementation with very-long-chain marine polyunsaturated n-3 fatty acids (n-3 PUFA) have cardioprotective effects, however these results are not without controversy. Study population, sample-size, type of supplementation and type of endpoint have all varied widely accross different studies.
Therefore, the aims of the present study are to evaluate the effect of 2 years supplementation with capsules of very-long chain marine n-3 PUFA on top of standard therapy in elderly patients after acute myocardial infarction (AMI).
In addition, special characteristics of this population with regard to prediction of clinical outcome will be investigated. The hypothesis is that this supplementation on top of modern therapy will reduce the occurence of major cardiovascular events (MACE). We present the design of the OMEMI (OMega-3 fatty acids in Elderly patients with Myocardial Infarction) study.
Methods/Design
The OMEMI study is designed as a randomized, placebo-controlled double-blind multicenter trial.
Included are patients ≥70-82 years of age who have sustained AMI. Patients of either gender are eligible. Sample size calculation based on existing literature has resulted in the need for 1400 patients followed for 2 years, based on the assumption that the n-3 PUFA supplementation will reduce MACE with 30%. The study medication is Pikasol® Axellus AS, Norway, 3 capsules (1.8 g eicosapentaenoic acid (EPA) + docohexaenoic acid (DHA)) per day, and matching placebo is corn oil. The Primary end-point is the composite of total mortality, first non-fatal recurring AMI, stroke and revascularization. Secondary end-point is the occurrence of new onset atrial fibrillation. Extensive biobanking will be performed, including adipose tissue biopsies. Compliance will be assessed by measurements of the fatty acid profile in serum, sampled at inclusion, after 12 months and at the end of study.
Discussion
The OMEMI study is scheduled to terminate when the last included patient has been followed for 2 years. To the best of our knowledge, the OMEMI study is the first to evaluate the effect of n-3 PUFAs on CVDs and mortality in a high risk elderly population having suffered an acute myocardial infarction.
Trial registration
ClinicalTrials.gov, NCT01841944
doi:10.1186/1471-2318-14-74
PMCID: PMC4074832  PMID: 24928284
Omega 3 fatty acids; Acute myocardial infarction; Randomized placebo controlled trial; Elderly
9.  Improvements in gait characteristics after intensive resistance and functional training in people with dementia: a randomised controlled trial 
BMC Geriatrics  2014;14:73.
Background
Preventing and rehabilitating gait disorders in people with dementia during early disease stage is of high importance for staying independent and ambulating safely. However, the evidence gathered in randomized controlled trials (RCTs) on the effectiveness of exercise training for improving spatio-temporal gait parameters in people with dementia is scarce. The aim of the present study was to determine whether a specific, standardized training regimen can improve gait characteristics in people with dementia.
Methods
Sixty-one individuals (mean age: 81.9 years) with confirmed mild to moderate stage dementia took part in a 3-month double-blinded outpatient RCT. Subjects in the intervention group (IG) received supervised, progressive resistance and functional group training for 3 months (2 times per week for two hours) specifically developed for people with dementia. Subjects in the control group (CG) conducted a low-intensity motor placebo activity program. Gait characteristics were measured before and after the intervention period using a computerized gait analysis system (GAITRite®).
Results
Adherence to the intervention was excellent, averaging 91.9% in the IG and 94.4% in the CG. The exercise training significantly improved gait speed (P < 0.001), cadence (P = 0.002), stride length (P = 0.008), stride time (P = 0.001), and double support (P = 0.001) in the IG compared to the CG. Effect sizes were large for all gait parameters that improved significantly (Cohen’s d: 0.80-1.27). No improvements were found for step width (P = 0.999), step time variability (P = 0.425) and Walk-Ratio (P = 0.554). Interestingly, low baseline motor status, but not cognitive status, predicted positive training response (relative change in gait speed from baseline).
Conclusion
The intensive, dementia-adjusted training was feasible and improved clinically meaningful gait variables in people with dementia. The exercise program may represent a model for preventing and rehabilitating gait deficits in the target group. Further research is required for improving specific gait characteristics such as gait variability in people with dementia.
Trial registration
ISRCTN49243245
doi:10.1186/1471-2318-14-73
PMCID: PMC4062767  PMID: 24924703
10.  Potentially inappropriate prescribing among older people in the United Kingdom 
BMC Geriatrics  2014;14:72.
Background
Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators.
Methods
A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison.
Results
Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70–74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics.
Conclusions
PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.
doi:10.1186/1471-2318-14-72
PMCID: PMC4091750  PMID: 24919523
Potentially inappropriate prescribing; Older people; Screening tool of older persons potentially inappropriate Prescriptions (STOPP); CPRD
11.  Risk of death or hospital admission among community-dwelling older adults living with dementia in Australia 
BMC Geriatrics  2014;14:71.
Background
Older people living with dementia prefer to stay at home to receive support. But they are at high risk of death and/or hospital admissions. This study primarily aimed to determine risk factors for time to death or hospital admission (combined) in a sample of community-dwelling older people living with dementia in Australia. As a secondary study purpose, risk factors for time to death were also examined.
Methods
This study used the data of a previous project which had been implemented during September 2007 and February 2009. The original project had recruited 354 eligible clients (aged 70 and over, and living with dementia) for Extended Aged Care At home Dementia program services during September 2007 and 2008. Client information and carer stress had been collected from their case managers through a baseline survey and three-monthly follow-up surveys (up to four in total). The principal data collection tools included Global Deterioration Scale, Modified Barthel Index, Instrumental-Dependency OARS, Adapted Cohen-Mansfield Agitation Inventory, as well as measures of clients’ socio-demographic characteristics, service use and diseases diagnoses. The sample of our study included 284 clients with at least one follow-up survey. The outcome variable was death or hospital admission, and death during six, nine and 16-month study periods. Stepwise backwards multivariate Cox proportional hazards analysis was employed, and Kaplan-Meier survival analysis using censored data was displayed.
Results
Having previous hospital admissions was a consistent risk factor for time to death or hospital admission (six-month: HR = 3.12; nine-month: HR = 2.80; 16-month: HR = 2.93) and for time to death (six-month: HR = 2.27; 16-month: HR = 2.12) over time. Previously worse cognitive status was a consistent risk factor over time (six- and nine-month: HR = 0.58; 16-month: HR = 0.65), but no previous use of community care was only a short-term risk factor (six-month: HR = 0.42) for time to death or hospital admission.
Conclusions
Previous hospital admissions and previously worse cognitive status are target intervention areas for reducing dementia clients’ risk of time to death or hospital admission, and/or death. Having previous use of community care as a short-term protective factor for dementia clients’ time to death or hospital admission is noteworthy.
doi:10.1186/1471-2318-14-71
PMCID: PMC4057809  PMID: 24912483
Death or hospital admission; Community-dwelling; Risk factors; Dementia
12.  Multimorbidity and long-term care dependency—a five-year follow-up 
BMC Geriatrics  2014;14:70.
Background
Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency.
Methods
This study is based on claims data from a German health insurance company. We included 115,203 people (mean age: 71.5 years, 41.4% females). To identify chronic diseases and multimorbidity, we used a defined list of 46 chronic conditions based on ICD-10 codes. Multimorbidity was defined as three or more chronic conditions from this list. The main outcome was “time until long-term care dependency”. The follow-up started on January 1st, 2005 and lasted for 5 years until December 31st, 2009. To evaluate differences between those with multimorbidity and those without, we calculated Kaplan–Meier curves and then modeled four distinct Cox proportional hazard regressions including multimorbidity, age and sex, the single chronic conditions, and disease clusters.
Results
Mean follow-up was 4.5 years. People with multimorbidity had a higher risk of becoming care dependent (HR: 1.85, CI 1.78–1.92). The conditions with the highest risks for long-term care dependency are Parkinson’s disease (HR: 6.40 vs. 2.68) and dementia (HR: 5.70 vs. 2.27). Patients with the multimorbidity pattern “Neuropsychiatric disorders” have a 79% higher risk of care dependency.
Conclusions
The results should form the basis for future health policy decisions on the treatment of patients with multiple chronic diseases and also show the need to introduce new ways of providing long-term care to this population. A health policy focus on chronic care management as well as the development of guidelines for multimorbidity is crucial to secure health services delivery for the older population.
doi:10.1186/1471-2318-14-70
PMCID: PMC4046081  PMID: 24884813
Long-term care; Multimorbidity; Claims data; Cox regression
13.  Can an e-learning course improve nursing care for older people at risk of delirium: a stepped wedge cluster randomised trial 
BMC Geriatrics  2014;14:69.
Background
Delirium occurs frequently in older hospitalised patients and is associated with several adverse outcomes. Ignorance among healthcare professionals and a failure to recognise patients suffering from delirium have been identified as the possible causes of poor care. The objective of the study was to determine whether e-learning can be an effective means of improving implementation of a quality improvement project in delirium care. This project aims primarily at improving the early recognition of older patients who are at risk of delirium.
Methods
In a stepped wedge cluster randomised trial an e-learning course on delirium was introduced, aimed at nursing staff. The trial was conducted on general medical and surgical wards from 18 Dutch hospitals. The primary outcome measure was the delirium risk screening conducted by nursing staff, measured through monthly patient record reviews. Patient records from patients aged 70 and over admitted onto wards participating in the study were used for data collection. Data was also collected on the level of delirium knowledge of these wards’ nursing staff.
Results
Records from 1,862 older patients were included during the control phase and from 1,411 patients during the intervention phase. The e-learning course on delirium had a significant positive effect on the risk screening of older patients by nursing staff (OR 1.8, p-value <0.01), as well as on other aspects of delirium care. The number of patients diagnosed with delirium was reduced from 11.2% in the control phase to 8.7% in the intervention phase (p = 0.04). The e-learning course also showed a significant positive effect on nurses’ knowledge of delirium.
Conclusions
Nurses who undertook a delirium e-learning course showed a greater adherence to the quality improvement project in delirium care. This improved the recognition of patients at risk and demonstrated that e-learning can be a valuable instrument for hospitals when implementing improvements in delirium care.
Trial registration
The Netherlands National Trial Register (NTR). Trial number: NTR2885.
doi:10.1186/1471-2318-14-69
PMCID: PMC4046094  PMID: 24884739
Delirium; Education; Nurses; Quality improvement
14.  The effects of increased therapy time on cognition and mood in frail patients with a stroke who rehabilitate on rehabilitation units of nursing homes in the Netherlands: a protocol of a comparative study 
BMC Geriatrics  2014;14:68.
Background
Recovery after stroke is dependent on how much time can be spent on rehabilitation. Recently, we found that therapy time for older stroke patients on a rehabilitation unit of a nursing home could be increased significantly from 8.6 to at least 13 hours a week. This increase was attained by the implementation of interventions, focused on strength, mobility and balance. Nurses carried out these exercises with the patients during their daily activities. The aim of the present study is to investigate if increased therapy time has a positive effect on cognition, mood (depression and anxiety), and ADL in stroke patients.
Methods
A comparative single blind controlled study will be applied. Patients suffering from a stroke and staying on one of the rehabilitation units of the nursing homes are eligible for participation. Participants belong to the intervention group if they stay in two nursing homes where four interventions of the Clinical Nursing Rehabilitation Stroke Guideline were implemented. Participants who stay in two nursing homes where therapy is given according to the Dutch stroke Guideline, are included in the control group. Clinical neuropsychologists will assess patients’ cognitive functioning, level of depression (mood) and anxiety. Nurses will assess a Barthel Index score on a weekly basis (ADL). These variables are measured at baseline, after 8 weeks and at the moment when participants are discharged from the nursing home.
Discussion
The present study evaluates the effect of increased therapy time on cognition, mood (level of depression and anxiety), and ADL in stroke patients. When positive effects will be found this study can guide policy makers and practitioners on how to implement more therapy time on rehabilitation wards of nursing homes.
Trial registration
TNR Our study has been documented in the Dutch Trial Registration, TC = 3871.
doi:10.1186/1471-2318-14-68
PMCID: PMC4035715  PMID: 24884651
Stroke; Rehabilitation; Cognition; Mood; Activities of daily living; Clinical nursing rehabilitation stroke guideline
15.  Natural course of care dependency in residents of long-term care facilities: prospective follow-up study 
BMC Geriatrics  2014;14:67.
Background
Insight in the natural course of care dependency of vulnerable older persons in long-term care facilities (LTCF) is essential to organize and optimize individual tailored care. We examined changes in care dependency in LTCF residents over two 6-month periods, explored the possible predictive factors of change and the effect of care dependency on mortality.
Methods
A prospective follow-up study in 21 Dutch long-term care facilities. 890 LTCF residents, median age 84 (Interquartile range 79–88) years participated. At baseline, 6 and 12 months, care dependency was assessed by the nursing staff with the Care Dependency Scale (CDS), range 15–75 points. Since the median CDS score differed between men and women (47.5 vs. 43.0, P = 0.013), CDS groups (low, middle and high) were based on gender-specific 33% of CDS scores at baseline and 6 months.
Results
At baseline, the CDS groups differed in median length of stay on the ward, urine incontinence and dementia (all P < 0.001); participants in the low CDS group stayed longer, had more frequent urine incontinence and more dementia. They had also the highest mortality rate (log rank 32.2; df = 2; P for trend <0.001). Per point lower in CDS score, the mortality risk increased with 2% (95% CI 1%-3%). Adjustment for age, gender, cranberry use, LTCF, length of stay, comorbidity and dementia showed similar results. A one point decrease in CDS score between 0 and 6 months was related to an increased mortality risk of 4% (95% CI 3%-6%).
At the 6-month follow-up, 10% improved to a higher CDS group, 65% were in the same, and 25% had deteriorated to a lower CDS group; a similar pattern emerged at 12-month follow-up. Gender, age, urine incontinence, dementia, cancer and baseline care dependency status, predicted an increase in care dependency over time.
Conclusion
The majority of residents were stable in their care dependency status over two subsequent 6-month periods. Highly care dependent residents showed an increased mortality risk. Awareness of the natural course of care dependency is essential to residents and their formal and informal caregivers when considering therapeutic and end-of-life care options.
doi:10.1186/1471-2318-14-67
PMCID: PMC4049399  PMID: 24884563
Care dependency; Predictive factors; Variability; Mortality; Long-term care facility; Vulnerable older persons
16.  Psychometric properties of four fear of falling rating scales in people with Parkinson’s disease 
BMC Geriatrics  2014;14:66.
Background
Fear of falling (FOF) is commonly experienced in people with Parkinson’s disease (PD). It is a predictor of recurrent falls, a barrier to physical exercise, and negatively associated with health-related quality of life. A variety of rating scales exist that assess different aspects of FOF but comprehensive head-to-head comparisons of their psychometric properties in people with PD are lacking. The aim of this study was to evaluate the psychometric properties of four FOF rating scales in people with PD. More specifically, we investigated and compared the scales’ data completeness, scaling assumptions, targeting, and reliability.
Methods
The FOF rating scales were: the Falls Efficacy Scale-International (FES-I), the Swedish FES (FES(S)), the Activities-specific Balance Confidence scale (ABC), and the modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE). A postal survey was administered to 174 persons with PD. Responders received a second survey after two weeks.
Results
The mean (SD) age and PD duration of the 102 responders were 73 (8) and 7 (6) years, respectively. ABC had worse data completeness than the other scales (6.9 vs. 0.9–1.3% missing data). All scales had corrected item-total correlations exceeding 0.4 and showed acceptable reliabilities (Cronbach’s alpha and Intraclass Correlation Coefficient (ICC) >0.80) but only FES-I had ICC >0.90. The standard error of measurements ranged from 7% (FES-I) to 12% (FES(S)), and the smallest detectable differences ranged from 20% (FES-I) to 33% (FES(S)) of the total score ranges. ABC and FES(S) had substantially more outliers than mSAFFE and FES-I (10 and 15 vs. 3 and 4, respectively) when the two test occasions were compared.
Conclusions
When assessing FOF in people with PD, the findings in the present study favoured the choice of FES-I or mSAFFE. However, FES-I was the only scale with ICC >0.90 which has been suggested as a minimum when using a scale for individual comparisons.
doi:10.1186/1471-2318-14-66
PMCID: PMC4035736  PMID: 24884466
Parkinson disease; Psychometrics; Reliability of results; Self efficacy; Questionnaires
17.  Developing the principles of chair based exercise for older people: a modified Delphi study 
BMC Geriatrics  2014;14:65.
Background
Chair based exercise (CBE) is suggested to engage older people with compromised health and mobility in an accessible form of exercise. A systematic review looking at the benefits of CBE for older people identified a lack of clarity regarding a definition, delivery, purpose and benefits. This study aimed to utilise expert consensus to define CBE for older people and develop a core set of principles to guide practice and future research.
Methods
The framework for consensus was constructed through a team workshop identifying 42 statements within 7 domains. A four round electronic Delphi study with multi-disciplinary health care experts was undertaken. Statements were rated using a 5 point Likert scale of agreement and free text responses. A threshold of 70% agreement was used to determine consensus. Free text responses were analysed thematically. Between rounds a number of strategies (e.g., amended wording of statements, generation and removal of statements) were used to move towards consensus.
Results
16 experts agreed on 46 statements over four rounds of consultation (Round 1: 22 accepted, 3 removed, 5 new and 17 modified; Round 2: 16 accepted, 0 removed, 4 new and 6 modified; Round 3: 4 accepted, 2 removed, 0 new and 4 modified; Round 4: 4 accepted, 0 removed, 0 new, 0 modified).
Statements were accepted in all seven domains: the definition of CBE (5), intended users (3), potential benefits (8), structure (12), format (8), risk management (7) and evaluation (3).
The agreed definition of CBE had five components: 1. CBE is primarily a seated exercise programme; 2. The purpose of using a chair is to promote stability in both sitting and standing; 3. CBE should be considered as part of a continuum of exercise for frail older people where progression is encouraged; 4. CBE should be used flexibly to respond to the changing needs of frail older people; and 5. Where possible CBE should be used as a starting point to progress to standing programmes.
Conclusions
Consensus has been reached on a definition and a set of principles governing CBE for older people; this provides clarity for implementation and future research about CBE.
doi:10.1186/1471-2318-14-65
PMCID: PMC4039312  PMID: 24884392
Chair based exercise; Older people; Physical activity; Consensus development
18.  Comorbidity and prognostic indices do not improve the 5-year mortality prediction of components of comprehensive geriatric assessment in hospitalized older patients 
BMC Geriatrics  2014;14:64.
Background
Advancing age is associated with increased vulnerability to chronic health problems. Identifying factors that predict oldest-old status is vital for developing effective clinical interventions and public health strategies.
Methods
Observational prospective study of patients aged 75 years and older consecutively admitted to an Acute Geriatric Ward of a tertiary hospital. After a comprehensive geriatric assessment all patients were assessed for five comorbidity indices and two prognostic models. Univariate and multivariate logistic regression models were fitted to assess the association between each score and 5-year mortality. The ability of each score to predict mortality was assessed using the area under the receiver operating characteristic curve.
Results
122 patients were enrolled. All patients were followed up for five years. 90 (74%) of them died during the study period. In the logistic regression analyses, apart from age, cognitive impairment and Barthel Index, three indices were identified as statistically associated with 5-year mortality: the Geriatric Index of Comorbidity and the two prognostic indices. The multivariate model that combined age, sex, cognitive impairment and Barthel showed a good discriminate ability (AUC = 0.79), and it did not improve substantially after adding individually any of the indices.
Conclusions
Some prognostic models and the Geriatric Index of Comorbidity are better than other widely used indices such as the Charlson Index in predicting 5-year mortality in hospitalized older patients, however, none of these indices is superior to some components of comprehensive geriatric assessment.
doi:10.1186/1471-2318-14-64
PMCID: PMC4026058  PMID: 24886561
5-year mortality; Aged; Comorbidity scores; Multimorbidity; Comprehensive geriatric assessment
19.  The well-being of community-dwelling near-centenarians and centenarians in Hong Kong a qualitative study 
BMC Geriatrics  2014;14:63.
Background
Hong Kong has one of the highest life expectancy rankings in the world. The number of centenarians and near-centenarians has been increasing locally and internationally. The relative growth of this population is a topic of immense importance for population and health policy makers. Living long and living well are two overlapping but distinct research topics. We previously conducted a quantitative study on 153 near-centenarians and centenarians to explore a wide range of biopsychosocial correlates of health and “living long”. This paper reports a follow-up qualitative study examining the potential correlates of “living well” among near-centenarians and centenarians in Hong Kong.
Methods
Six cognitively, physically, and psychologically sound community-dwelling elders were purposively recruited from a previous quantitative study. Semi-structured interviews were conducted.
Results
Four major themes related to living long and well emerged from the responses of the participants: (a) Positive relations with others, (b) Positive events and happiness, (c) Hope for the future, and (d) Positive life attitude. Specifically, we found that having good interpersonal relationships, possessing a collection of positive life events, and maintaining salutary attitudes towards life are considered as important to psychological well-being by long-lived adults in Hong Kong. Most participants perceived their working life as most important to their life history and retired at very old ages.
Conclusions
These findings also shed light on the relationships between health, work, and old age.
doi:10.1186/1471-2318-14-63
PMCID: PMC4031324  PMID: 24886462
Ageing; Hong Kong SAR; Chinese culture; Community and public health; Health and well-being; Psychology; Psychosocial issues
20.  An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms 
BMC Geriatrics  2014;14:62.
Background
Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services.
Methods
A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation.
Results
Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period.
Conclusions
Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms.
Trial registration
Clinicaltrials.gov identifier: NCT01407926.
doi:10.1186/1471-2318-14-62
PMCID: PMC4019952  PMID: 24886344
Nurse-led interventions; Home care; Interdisciplinary; Depression management; Older adults; Clinical effectiveness
21.  Perceived economic situation, but not education level, is associated with disability prevalence in the Spanish elderly: observational study 
BMC Geriatrics  2014;14:60.
Background
The aim of this paper is to ascertain if the subjective perception of the economic situation of a household is associated with the prevalence of disability in old age, net of education level. Subjective economic perception is less non-response biased. Knowing if the self-perceived economic situation is related to disability over and above education level has important implications both for understanding the mechanisms that lead to disability and for selecting policies to reduce it.
Methods
This is a transversal study based on the pilot of the ELES survey, which is a representative survey of non-institutionalised Spaniards aged 50 and over. Only individuals whose job income levels were fixed before becoming disabled were selected to avoid the main source of reverse causality. Disability was defined as having difficulty in carrying out any of 12 activities of daily living. Education level, difficulty in making ends meet, self-perceived relative economic position of the household, age, gender, psychological disposition, and alcohol and tobacco consumption were introduced as independent variables in binary logistic models.
Results
The working sample is made up of 704 individuals of aged 60 and over. The subjective household economic situation, measured in two different ways, is strongly and consistently related with the prevalence of disability net of age, gender, education level and psychological disposition. After adjusting for age and gender, education level is no longer associated with disability. However, having economic difficulties has the same effect on disability prevalence as being 10 years older, or being a woman instead of a man.
Conclusions
As the economic situation of the elderly is much easier to improve than their formal education, our findings support feasible interventions which could lead to a reduction in the prevalence of disability.
doi:10.1186/1471-2318-14-60
PMCID: PMC4023527  PMID: 24886113
Aged; Disabled persons; Social class; Prevalence; Spain
22.  Factors associated with the goal of treatment in the last week of life in old compared to very old patients: a population-based death certificate survey 
BMC Geriatrics  2014;14:61.
Background
Little is known about the type of care older people of different ages receive at the end of life. The goal of treatment is an important parameter of the quality of end-of-life care. This study aims to provide an evaluation of the main goal of treatment in the last week of life of people aged 86 and older compared with those between 75 and 85 and to examine how treatment goals are associated with age.
Methods
Population- based cross sectional survey in Flanders, Belgium. A stratified random sample of death certificates was drawn of people who died between 1 June and 30 November 2007. The effective study sample included 3,623 deaths (response rate: 58.4%). Non-sudden deaths of patients aged 75 years and older were selected (N = 1681). Main outcome was the main goal of treatment in the last week of life (palliative care or life-prolonging/curative treatment).
Results
In patients older than 75, the main goal of treatment in the last week was in the majority of cases palliative care (77.9%). Patients between 75 and 85 more often received life-prolonging/curative treatment than older patients (26.6% vs. 15.8%). Most patient and health care characteristics are similarly related to the main goal of treatment in both age groups. The patient’s age was independently related to having comfort care as the main goal of treatment. The main goal of treatment was also independently associated with the patient’s sex, cause and place of death and the time already in treatment.
Conclusion
Age is independently related to the main goal of treatment in the last week of life with people over 85 being more likely to receive palliative care and less likely to receive curative/life-prolonging treatment compared with those aged 75–85. This difference could be due to the patient’s wishes but could also be the result of the attitudes of care givers towards the treatment of older people.
doi:10.1186/1471-2318-14-61
PMCID: PMC4024189  PMID: 24886232
Palliative care; End-of-life care; Older people
23.  Relationship of perceived environmental barriers and disability in community-dwelling elderly in Taiwan – a population-based study 
BMC Geriatrics  2014;14:59.
Background
To identify the relationship between perceived environmental barriers and disability in community-dwelling elderly.
Methods
Cross-sectional study in two community service centers in Tainan. We enrolled 200 community-dwelling residents, aged above 65 years, who had resided in the same community for at least 12 months. Basic activity of daily living (BADL) and instrumental activity of daily living (IADL) were assessed using the Hierarchy of Care Required (HCR). There were 59 participants in BADL disability and 109 in IADL disability. Perceived environmental barriers were assessed using the Craig Hospital Inventory of Environmental Factors (CHIEF). We used multinomial logistic regression to examine the relationship of perceived environmental barriers and disability.
Results
The presence of perceived environmental barriers was related to BADL disability (OR = 4.39, 95% CI = 1.01-19.11) and IADL disability (IADL with difficulty in 1–2 tasks: OR = 9.93, 95% CI = 3.22-30.56; IADL with difficulty in more than 2 tasks: OR = 8.40, 95% CI = 1.83-38.51). The presence of physically/structurally perceived environmental barriers was related to BADL disability (OR = 4.90, 95% CI = 1.01-23.86) and IADL disability (IADL with difficulty in 1–2 tasks: OR = 4.61, 95% CI = 1.27-16.76; IADL with difficulty in more than 2 tasks: OR = 17.05, 95% CI = 2.82-103.30).
Conclusions
Perceived environmental barriers are related to disability in community-dwelling elderly.
doi:10.1186/1471-2318-14-59
PMCID: PMC4013536  PMID: 24885956
Perceived environmental barriers; Disability; Community-dwelling elderly
24.  The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study 
BMC Geriatrics  2014;14:58.
Background
This study explored the effects of an integrated care model aimed at the frail elderly on the perceived health, objective burden, subjective burden and quality of life of informal caregivers.
Methods
A quasi-experimental design with before/after measurement (with questionnaires) and a control group was used. The analysis encompassed within and between groups analyses and regression analyses with baseline measurements, control variables (gender, age, co-residence with care receiver, income, education, having a life partner, employment and the duration of caregiving) and the intervention as independent variables.
Results
The intervention significantly contributed to the reduction of subjective burden and significantly contributed to the increased likelihood that informal caregivers assumed household tasks. No effects were observed on perceived, health, time investment and quality of life.
Conclusions
This study implies that integrated care models aimed at the frail elderly can benefit informal caregivers and that such interventions can be implemented without demanding additional time investments from informal caregivers. Recommendations for future interventions and research are provided.
Trial registration
Current Controlled Trials http://ISRCTN05748494. Registration date: 14/03/2013.
doi:10.1186/1471-2318-14-58
PMCID: PMC4021048  PMID: 24885828
Integrated care; Frail elderly; Informal caregiver; Perceived health; Objective burden; Subjective burden; Quality of life
25.  Potential for alcohol and drug interactions in older adults: evidence from the Irish longitudinal study on ageing 
BMC Geriatrics  2014;14:57.
Background
Older adults are susceptible to adverse effects from the concomitant use of prescription medications and alcohol. This study estimates the prevalence of exposure to alcohol interactive (AI) medications and concomitant alcohol use by therapeutic class in a large, nationally representative sample of older adults.
Methods
Cross-sectional analysis of a population based sample of older Irish adults aged ≥60 years using data from The Irish Longitudinal Study on Ageing (TILDA) (N = 3,815). AI medications were identified using Stockley’s Drug Interactions, the British National Formulary and the Irish Medicines Formulary. An in-home inventory of medications was used to characterise AI drug exposure by therapeutic class. Self-reported alcohol use was classified as non-drinker, light/moderate and heavy drinking. Comorbidities known to be exacerbated by alcohol were also recorded (diabetes mellitus, hypertension, peptic ulcer disease, liver disease, depression, gout or breast cancer), as well as sociodemographic and health factors.
Results
Seventy-two per cent of participants were exposed to AI medications, with greatest exposure to cardiovascular and CNS agents. Overall, 60% of participants exposed to AI medications reported concomitant alcohol use, compared with 69.5% of non-AI exposed people (p < 0.001). Almost 28% of those reporting anti-histamine use were identified as heavy drinkers. Similarly almost one in five, combined heavy drinking with anti-coagulants/anti-platelets and cardiovascular agents, with 16% combining heavy drinking with CNS agents. Multinomial logistic regression showed that being male, younger, urban dwelling, with higher levels of education and a history of smoking, were associated with an increased risk for concomitant exposure to alcohol consumption (both light/moderate and heavier) and AI medications. Current smokers and people with increasing co-morbidities were also at greatest risk for heavy drinking in combination with AI medications.
Conclusions
The concurrent use of alcohol with AI medications, or with conditions known to be exacerbated by alcohol, is common among older Irish adults. Prescribers should be aware of potential interactions, and screen patients for alcohol use and provide warnings to minimize patient risk.
doi:10.1186/1471-2318-14-57
PMCID: PMC4008399  PMID: 24766969
Drug interactions; Alcohol interactive medications; Alcohol drinking/epidemiology; Aged

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